Acceptance and Commitment Therapy for Problematic Internet Pornography
Use: A Randomized Trial

Jesse M. Crosby, Michael P. Twohig

PII: S0005-7894(16)00017-4
DOI: doi: 10.1016/j.beth.2016.02.001
Reference: BETH 609

To appear in: Behavior Therapy

Received date: 7 March 2014

Accepted date: 2 February 2016

Please cite this article as: Crosby, J.M. & Twohig, M.P., Acceptance and Commitment
Therapy for Problematic Internet Pornography Use: A Randomized Trial, Behavior Ther-
apy (2016), doi: 10.1016/j.beth.2016.02.001

This is a PDF file of an unedited manuscript that has been accepted for publication.
As a service to our customers we are providing this early version of the manuscript.
The manuscript will undergo copyediting, typesetting, and review of the resulting proof
before it is published in its final form. Please note that during the production process
errors may be discovered which could affect the content, and all legal disclaimers that
apply to the journal pertain.
 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 1

Acceptance and Commitment Therapy for Problematic Internet Pornography Use:

A Randomized Trial

PT
Jesse M. Crosby

RI
McLean Hospital / Harvard Medical School

&

SC
Utah State University

NU
Michael P. Twohig
MA
Utah State University
D
P TE

Corresponding Author:
CE

Jesse M. Crosby, Ph.D.

AC

115 Mill Street, Belmont, MA 02478

Phone: (617) 855-4426

Email: jcrosby@mclean.harvard.edu
 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 2

Abstract

Problematic internet pornography use is the inability to control the use of pornography,

the experience of negative cognitions or emotions regarding pornography use, and the resulting

PT
negative effects on quality of life or general functioning. This study compared a 12-session

RI
individual protocol of acceptance and commitment therapy (ACT) for problematic internet

pornography use to a waitlist control condition with 28 adult males, all but one of whom were

SC
members of the Church of Jesus Christ of Latter-day Saints. Measures of self-reported

NU
pornography viewing, standardized measures of compulsive sexual behavior and related

cognitions, and quality of life occurred at pretreatment, posttreatment, and three-month follow-
MA
up. Results demonstrate significant between-condition reductions in pornography viewing

compared to the waitlist condition (93% reduction ACT vs. 21% waitlist). When combining all
D
TE

participants (N=26), a 92% reduction was seen at posttreatment and an 86% reduction at three-

month follow-up. Complete cessation was seen in 54% of participants at posttreatment and at
P

least a 70% reduction was seen in 93% of participants. At the three-month follow-up assessment,
CE

35% of participants showed complete cessation, with 74% of participants showing at least 70%
AC

reduction in viewing. Treatment suggestions and future directions are discussed.

 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 3

Acceptance and Commitment Therapy for Problematic Internet Pornography Use:

A Randomized Trial

Research on problematic internet pornography use is often referred to in the literature as

PT
problematic or compulsive sexual behavior, and much of the focus of this research has been on

RI
how best to conceptualize and diagnose the behavior. Conceptualizations have included sexual or

pornography addiction (Hilton Jr & Watts, 2011; Orzack & Ross, 2000), sexual impulsivity

SC
(Mick & Hollander, 2006), compulsive sexual behavior (Coleman, 1991), sexual compulsivity

NU
(Cooper, Putnam, Planchon, & Boies, 1999), out-of-control sexual behavior (Salisbury, 2008),

and hypersexual behavior or hypersexuality (Rinehart & McCabe, 1998) which was proposed,
MA
but ultimately not included in, the Diagnostic and Statistical Manual of Mental Disorders-5

(Reid et al., 2012). Three formal classes of disorders have been used to provide criteria and
D
TE

terminology to conceptualize problematic sexual behavior: (a) substance use disorders

(Schneider, 1994), (b) impulse control disorders (Grant & Potenza, 2010), and (c) obsessive-
P

compulsive spectrum disorders (Black, 1998).

CE

Problematic internet pornography is generally defined by the inability to control the use
AC

of pornography, the experience of negative cognitions or emotions regarding pornography use,

and the resulting negative effects on quality of life or general functioning (Coleman, Miner,

Ohlerking, & Raymond, 2001; McBride, Reece, & Sanders, 2008; Reid, 2007). This could

include damaged relationships, loss of productivity, impaired performance at work or school, job

loss, financial expenses, guilt/shame, personal distress, and other forms of psychopathology

(McBride et al., 2008). Additionally, problematic pornography use has been identified as a major

contributing factor to marital separation and divorce (Dedmon, 2002; Schneider, 2000). Similar

to other clinical behaviors, the use of pornography is not viewed as inherently problematic. It is
 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 4

problematic only to the extent to which it becomes excessive and leads to problematic emotional,

cognitive, or behavioral outcomes (Twohig, Crosby, & Cox, 2009).

It is estimated that 3% to 6% of the general US adult population meets criteria for

PT
compulsive sexual behavior (Kuzma & Black, 2008), and that approximately half of these

RI
individuals have an interest in pornography as part of their compulsive behavior (Black,

Kehrberg, Flumerfelt, & Schlosser, 1997), leading to an estimate of about 1.5% to 3% of the US

SC
general adult population. With the increased use of the internet, that number is likely an

NU
underestimate. For example, a study of over 9000 internet users found that between 9% and 15%

of the participants reported distress related to their use of the internet for sexual purposes and
MA
10% reported their behavior as “addictive” (Cooper, Delmonico, Griffin-Shelley, & Mathy,

2004). In a survey of over 9000 individuals who had accessed pornographic or sexual content on
D
TE

the internet, 17% scored in the problematic range for sexual compulsivity (Cooper, Delmonico,

& Burg, 2000). In another survey of males involved in online sexual activity, 6.5% reported
P

problematic outcomes as a result of internet sexual behaviors (Cooper, Griffin-Shelley,

CE

Delmonico, & Mathy, 2001). In a study of Swedish men and women, 5% of women and 13% of
AC

men reported some problems with sexual internet use and 2% of women and 5% of men reported

serious problems with sexual internet use (Ross, Månsson, & Daneback, 2012). There is

particular concern about the prevalence of these behaviors among adolescents, where general

internet use is high and it is assumed that problematic sexual use of the internet occurs for a

percentage of that general sample (Owens, Behun, Manning, & Reid, 2012).

For compulsive sexual behaviors in general, as well as problematic internet pornography

use specifically, no randomized controlled investigations of psychosocial treatments exist. The

treatments that have been suggested or investigated include motivational interviewing (Del
 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 5

Giudice & Kutinsky, 2007), cognitive behavior therapy (Young, 2007), 12-step programs

(Schneider, 1994), and emotion-focused therapy (Reid & Woolley, 2006). Although these

recommendations are promising, they are not supported with controlled outcome work and the

PT
uncontrolled work that does exist is often with variants of problematic internet pornography use

RI
(e.g., compulsive internet use, relationship problems from viewing; Winkler et al., 2013).

Current research on the way inner experiences (i.e., thoughts, emotions, physical

SC
sensations) are addressed and function may have important implications for the understanding

NU
and treatment of problematic pornography use. Multiple studies have shown that the way one

interacts with urges to view pornography affects not only the rate of viewing, but emotional
MA
distress from viewing and problems related to viewing (Levin, Lillis, & Hayes, 2012; Twohig et

al., 2009). Struggling with thoughts is an important part of how sexual compulsivity is defined
D
TE

and measured (Reid, Bramen, Anderson, & Cohen, 2013). Indeed, a commonly used measure of

sexual compulsivity (Cognitive and Behavioral Outcomes of Sexual Behavior Scale; McBride et
P

al., 2008) assesses individuals' difficulty controlling sexual thoughts and behaviors (Kalichman
CE

& Rompa, 1995).

AC

Given that attempts to regulate certain thoughts and urges are not helpful in the long run,

research has focused on the utility of acceptance and mindfulness-based procedures (Levin,

Hildebrandt, Lillis, & Hayes, 2012), especially when applied to intrusive thoughts (Marcks &

Woods, 2007). Acceptance-based procedures foster open experience of internal experience

instead of attempts to regulate them. This is the focus of acceptance and commitment therapy

(ACT; Hayes, Strosahl, & Wilson, 1999), and suggests that ACT may be an effective treatment

for problematic pornography use. ACT targets processes that generally aim to decrease the

effects of inner experiences (e.g., urges to use pornography) on overt behavior and increase the
 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 6

effects of other inner experiences (e.g., studies investigating values-based work or defusion in

isolation) on behavior. This is consistent with a recent study showing that lack of mindfulness is

positively related to hypersexuality beyond emotion dysregulation, impulsivity, and stress (Reid

PT
et al., 2013).

RI
There is a growing body of research in support of ACT for the treatment of a wide variety

of disorders (Hayes, Luoma, Bond, Masuda, & Lillis, 2006), including disorders to which

SC
problematic pornography use is most often compared (OCD, impulse control disorders, and

NU
substance use disorders). The specific ACT processes of change are also supported in component

studies (e.g., studies of values or defusion only), showing that improvement of those processes
MA
outside of a large treatment package is clinically useful (Levin, Hildebrandt, et al., 2012). The

case for applying ACT to problematic internet pornography use is strengthened further by
D
TE

preliminary work with ACT for problematic pornography use in a single subjects design study

(Twohig & Crosby, 2010). This study tested the effectiveness of ACT with six adult male
P

participants treated in eight 1.5-hour sessions. Treatment resulted in an 85% reduction in viewing
CE

at posttreatment with results being maintained at 3-month follow-up (83% reduction). These
AC

findings, coupled with the lack of treatment outcome work in this area, suggest the need for a

larger controlled trial of ACT for problematic internet pornography use.

Method

Participants

Participants were recruited by newspaper advertisements, flyers placed throughout the

community, and announcements in university classes. Participants were eligible to enroll if they

met criteria for problematic pornography use established from preliminary investigations as no

formal diagnostic criteria have been established (Twohig & Crosby, 2010). The criteria for
 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 7

inclusion were: (a) the individual must have engaged in problematic internet pornography use for

more than 6 months; (b) the individual must have viewed pornography with a frequency of at

least two sessions per week, on average, for the month previous to enrolling in the study; (c) the

PT
individual must have experienced significant distress and/or functional impairment in his life;

RI
and (d) the individual must have had at least one unsuccessful attempt at stopping the behavior.

Participants were ineligible if they (a) were currently receiving psychotherapy; (b) started,

SC
changed, or were planning to change a psychotropic medication within 30 days; (c) were not

NU
capable of participating in the research due to physical/medical complications; (d) met criteria

for substance dependence; or (e) had been diagnosed with an intellectual or developmental
MA
disability. Eligibility was assessed using a semi-structured interview to assess all inclusion and

exclusion criteria for the study. In addition, an abbreviated version of the Structured Clinical
D
TE

Interview for DSM-IV Axis I Disorders, Clinician Version (SCID-C; First, Spitzer, Gibbon, &

Williams, 2012) was administered.

P
CE

Twenty-eight participants met eligibility requirements for participation in the study. All

participants were male with an average age of 29.3 (SD=11.4). Most participants were married
AC

(54%) and 92% were white American. Even though participants were recruited from the

community of a medium sized city, all but one participant were members of the Church of Jesus

Christ of Latter-day Saints. This is likely the result of the majority of citizens in the town being

members of that church, and pornography being against their religious beliefs. On average, they

had struggled with pornography use for 13.6 years (SD=11.8). All participants reported viewing

pornography on the internet, and others additionally reported viewing it in magazines (n=3), via

cable or satellite television (n=5), or video rental (n=1). Other problematic sexual actions were

as follows: phone/internet sex with strangers (n=3), strip clubs (n=1), infidelity (n=1), and hiring
 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 8

of prostitutes (n=1). All had tried to stop viewing with many attempting individual

psychotherapy (n=13), followed by group therapy (n=4), 12-step programs (n=7), religious

counseling (n=6), and using self-help (n=2). According to the SCID-C, comorbid diagnoses were

PT
as follows: major depressive disorder (n=5), bipolar disorder (n=1), generalized anxiety disorder

RI
(n=2), and OCD (n=1). Use of psychotropic medications were as follows: antidepressants (n=3),

mood stabilizers (n=1), and antipsychotics (n=1). Participants were randomly assigned to one of

SC
two conditions (n=14 ACT, n=14 wait list). Results showed no statistical difference between the

NU
ACT and the control conditions on any pretreatment variables. Participant flow is reported in

Figure 1.
MA
Measures

Background Information. Participants completed questions about sex, marital status,

D
TE

age, religion, ethnicity/race, years of pornography viewing, how they accessed pornography,

other problematic sexual behaviors, previous treatment attempts for problematic pornography
P

viewing, and current psychotropic medications.

CE

Daily Pornography Viewing Questionnaire (DPVQ). We administered the Daily

AC

Pornography Viewing Questionnaire (DPVQ), which was developed for purposes of this study.

The DPVQ is a modified version of the Daily Drinking Questionnaire (DDQ; Collins, Parks, &

Marlatt, 1985), an instrument originally developed to measure the quantity of alcohol use as well

as hours spent engaging in alcohol consumption. The format of the DDQ improves the accuracy

of self report and has been shown to be valid and reliable (Baer, Stacy, & Larimer, 1991;

Neighbors, Lee, Lewis, Fossos, & Larimer, 2007). Our modified version, the DPVQ, was similar

in format to the DDQ but was instead used to measure weekly sessions of pornography viewing

and the number of hours spent viewing pornography for each day of the week, as well as
 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 9

other items not reported in this manuscript. The daily results were reported to the therapist at

each weekly session. Weekly hour totals were obtained by summing the results from each

weekday.

PT
Sexual Compulsivity Scale (SCS). The SCS (Kalichman et al., 1994) consists of 10

RI
items designed to assess sexual compulsivity. Seven of the items address sexual desires and how

an individual reacts to them, and three of the items focus more on the negative effects of sexual

SC
thoughts and behaviors. The SCS has been shown to have adequate validity and reliability

NU
(Dodge, Reece, Cole, & Sandfort, 2004; Kalichman et al., 1994; Kalichman & Rompa, 1995;

Perry, Accordino, & Hewes, 2007). It is internally consistent (α = .86) and has test-retest
MA
reliability of .64. The SCS has also been found to be predictive of internal difficulties (e.g.,

loneliness, low self-esteem, and beliefs about self-control; Kalichman et al., 1994) and lack of
D
TE

intention to change potentially problematic sexual behaviors (Kalichman & Rompa, 1995). The

SCS has been shown to predict problematic sexual behaviors, and it predicts internal events that
P

are conducive to engaging in sexual behaviors that are likely to be problematic. Cronbach’s
CE

alpha at pretreatment was .90.

AC

Cognitive and Behavioral Outcomes of Sexual Behavior Scale (CBOSB)--Cognitive

Subscale. The CBOSB (McBride et al., 2008) consists of 20 items measuring worries about

negative consequences of sexual practices over the last year. The CBOSB has demonstrated

adequate reliability and validity (McBride et al., 2008). Internal consistency for the CBOSB

cognitive scale has been high (α = .89). The construct validity of the subscale has been

demonstrated using a principal component analysis in which the six factors/subscales explained

74.8% of the total variance. Cronbach’s alpha at pretreatment was .70.

Quality of Life Scale (QOLS). The QOLS (Burckhardt & Anderson, 2003) is a 16-item
 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 10

scale that measures how satisfied people are with the quality of their lives in several areas (e.g.,

relationships, employment, health, recreation), and has been used in a variety of populations. The

items are rated on a 1-7 point scale where 1 = “terrible,” and 7 = “delighted.” Convergent and

PT
discriminant validity was shown in that the QOLS was highly correlated with a measure of life

RI
satisfaction (r=.68 to.75), but had lower correlations with a measure of physical health (r=.25 to

.48). The measure is scored by summing the scores for all 16 items. It has been found to be

SC
internally consistent (α = .89 to .92), and has demonstrated temporal stability (r = .78 to .84) over

NU
three weeks. Cronbach’s alpha at pretreatment was .86.

Procedures
MA
The effects of the treatment were assessed through a randomized controlled trial with a

waitlist control condition, with the waitlist condition receiving treatment after the waiting period.
D
TE

Follow-up assessments were collected three months after treatment. Participants responded to

the recruitment efforts by phone or email and any questions or concerns regarding the study were
P

answered. After agreeing to participate in the study, participants attended a 2-hour pretreatment
CE

session during which they were provided with an Institutional Review Board -approved informed
AC

consent for their review and signature. This initial session also included the interviews to assess

for eligibility and the administration of the measures to gather information on the participants’

backgrounds, relevant difficulties, and other information pertaining to the research questions. To

assess the effectiveness of ACT, the assessments were administered at posttreatment for the ACT

condition and after a 12-week waiting period for the waitlist condition. The waitlist condition

was offered treatment after their second assessment, and posttreatment assessment was

completed after treatment was completed. All participants completed a follow-up assessment 12

weeks after treatment was completed.

 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 11

After completing the pretreatment assessment, participants were randomly placed in

either an ACT or a waitlist condition. Analyses showed no statistical difference between ACT

and the control conditions on age, education level, marital status, years of viewing, hours

PT
viewing per week, or any of the dependent measures. Participants in the ACT condition began

RI
treatment immediately after randomization. Participants in the waitlist condition began treatment

after 12 weeks had elapsed and they had completed the post-waitlist assessment.

SC
Treatment

NU
ACT for problematic pornography use. A 10-session ACT manual for problematic

pornography use (Twohig & Crosby, 2010) was modified and expanded for this study.
MA
Treatment consisted of 12 individual weekly 1-hour sessions of ACT. The goals of this treatment

protocol were: (a) to help the client determine effective strategies for responding to urges to
D
TE

engage in the pornography use, (b) to practice using these strategies outside of session, (c) to

gradually decrease pornography use, and (d) to increase occurrence of high quality of life
P

activities. Table 1 provides a summary of the treatment components and specific interventions
CE

used. A copy of the complete manual is available from the corresponding author.
AC

Treatment Adherence. The intervention was provided by the first author (23

participants), the second author (2 participants), and an advanced graduate student (3

participants). Both graduate student therapists were supervised by the second author, who is a

licensed psychologist. All of the treatment sessions were recorded (video and audio) to monitor

treatment integrity. A sample of the sessions (68 of 315, 21.59%) was selected to be viewed and

scored for treatment integrity using a standardized treatment integrity scoring system used in

previous ACT research (Plumb & Vilardaga, 2010). The sessions to be reviewed were selected

systematically and objectively so that of the 12 total sessions, approximately three sessions from
 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 12

each participant and six of each session number were reviewed. The review of the sessions was

conducted by three trained graduate students who showed high reliability (.90 or greater) with

the senior (MPT) assessor on two consecutive videos. The graduate students all worked in a

PT
laboratory that focuses on ACT, but in addition, three two-hour sessions on how to score

RI
occurred prior to testing on the assessing protocol.

In the standardized scoring system, sessions were scored for both the quantity and the

SC
quality of coverage of each ACT process on a 5-point Likert scale. For quantity of coverage, 1 =

NU
the process was never explicitly covered, 2 = the process occurred at least once and not in an in-

depth manner, 3 = the process occurred several times and was covered at least once in a
MA
moderately in-depth manner, 4 = the process occurred with relatively high frequency and was

addressed in a moderately in-depth manner, and 5 = the process occurred with high frequency
D
TE

and was covered in a very in-depth manner. The review showed that all of the ACT processes

were rated as a 5 in at least one of the reviewed sessions, indicating that all of the ACT processes
P

were covered in depth in at least one session. The mean ratings for each process over all 12
CE

sessions were: acceptance = 3.50 (SD = 1.24), defusion = 3.76 (SD = 1.40), self as context = 1.68
AC

(SD = 1.20), contact with the present moment = 1.62 (SD = 1.04), values = 2.37 (SD = 1.53), and

committed action = 2.40 (SD = 1.43). Sessions were also reviewed for intervention techniques

that are inconsistent with the ACT model, including challenging cognitions, suggesting that

thoughts or feelings can cause behavior, and behavioral management strategies to avoid triggers

of private events. The ACT-inconsistent measures received scores of 1, indicating that these

techniques were not used in treatment. In addition, although sessions were scored using the

standardized approach, the same reviewers were also trained to record observations at each

minute of the recording to identify which processes were being targeted in that time period.
 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 13

Across all participants and therapy sessions, it was shown that each processes of change was

addressed the following percent of time: acceptance (30%), defusion (37%), self as context (4%),

being present (4%), values (10%), committed action (15%), and general assessment (23%).

PT
Cognitive challenging and stimulus management never occurred.

RI
Data Management

The data were collected using printed questionnaire materials, and the administrators of

SC
the questionnaires checked for missing data at the time of completion. There were no missing

NU
items. Three participants did not complete an assessment time point. As seen in Figure 1, one

participant in the ACT condition did not respond to attempts to schedule the follow-up
MA
assessment. One participant in the waitlist condition moved out of state during the waiting

period, and attempts to collect the remaining assessments were unsuccessful. Two participants in
D
TE

the waitlist condition received a partial intervention (six sessions and nine sessions) because they

moved out of state during the intervention. Of these two, one successfully completed the
P

remaining posttreatment and follow-up assessments. The other did not complete the remaining
CE

assessments. Last observation carried forward (LOCF) was not utilized in this study because
AC

moving posttreatment to follow-up for the ACT condition, and moving pretreatment to the end of

the waitlist for the waitlist condition, would have biased the outcomes in favor of the active

condition. Finally, LOCF was not used for the participant who completed 9 of 12 sessions but

did not complete post-assessment because this would not have accurately represented his gains

seen from the sessions he did complete.

Data Analysis

Two sets of analyses were completed on the acquired data. First, “between condition”

analyses were conducted using the pretreatment and posttreatment data for all participants. These
 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 14

comparisons began with a 2 (Condition: ACT, waitlist) X 2 (Time: pretreatment, posttreatment)

MANOVA on the four measures. Because the interaction from the MANOVA was significant,

the univariate post hoc analyses were analyzed. Significant univariate 2X2 interactions were

PT
followed up with paired samples t-tests comparing pretreatment to posttreatment for each

RI
condition.

Because the waiting list condition received the treatment after the waiting period, both

SC
conditions’ data were combined and analyzed from pretreatment to posttreatment, and to follow-

NU
up. The “combined” analyses were completed by using the ACT condition’s pretreatment,

posttreatment, and three month follow-up data and the waitlist’s second assessment point
MA
(functioning as a pretreatment point because no treatment was delivered yet), posttreatment

(third assessment point), and three month follow-up (fourth assessment point). To ensure that the
D
TE

pretreatment assessment from each condition was equivalent, another randomization check was

conducted with select variables (variables that could have changed during the waiting period).
P

There were no significant differences between the immediate treatment condition and the second
CE

pretreatment assessment on measures of years of pornography use, average hours viewing per
AC

week, quality of life, or scores on the sexual compulsivity scale. These data were then combined

into a dataset with three timepoints and no group distinction: pretreatment, posttreatment, follow-

up. For the combined analyses a, 1-way (Time: pretreatment, posttreatment, follow-up)

MANOVA on the 4 measures was conducted. Because the multivariate effect was significant,

the univariate effects for time were interpreted for each measure. Pairwise post hoc comparisons

between pretreatment and posttreatement, pretreatment and follow-up, as well as posttreatment

and follow-up were conducted for each measure following a significant effect for time.
 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 15

Results

Between-condition Analyses

The 2 (Condition: ACT, waitlist) X 2 (Time: pretreatment, posttreatment) MANOVA

PT
showed significant multivariate effects for time F(4,22) = 5.35, p = .004, partial η2 = .5 and the

time X condition interaction F(4,22) = 3.17, p < .034, partial η2 = .366, but not for condition

RI
F(4,22) = 2.57, p < .066, partial η2 = .318. Follow-up univariate analyses showed that there were

SC
significant 2 (condition) X 2 (time) interactions for each dependent variable (ps ≤ .05). All

NU
means, standard deviations, and pretreatment to posttreatment effect sizes are reported in Table

2.
MA
For the DPVQ (self-reported hours per week of viewing pornography), univariate

analyses showed a significant condition X time interaction, F(1, 25) = 6.42, p = .018, partial η2 =
D
TE

.20. A post-hoc analysis comprised of paired samples t-tests (pretreatment to posttreatment) for

each condition showed a significant reduction in the ACT condition, t(13) = 4.81, p = .001, but
P

not the waitlist condition, t(12) = 1.21, p = .25. As shown in Table 2, the ACT condition
CE

experienced a significant decrease (93%) in hours viewed from pretreatment to posttreatment

AC

when compared to the control condition, which experienced a 21% decrease.

For the QOLS, univariate analyses showed a significant condition X time interaction,

F(1, 25) = 4.23, p = .05, partial η2 = .15. A post-hoc analysis comprised of paired samples t-tests

for each condition did not show a significant reduction in the ACT condition, t(13) = -1.02, p =

.33, and the waitlist showed a significant worsening, t(12) = 2.37, p = .035.

For the SCS, univariate analyses showed a significant condition X time interaction, F(1,

25) = 7.8, p = .01, partial η2 = .24. A post-hoc analysis comprised of paired samples t-tests for

each condition showed a significant reduction in the ACT condition, t(13) = 4.76, p = .001, but
 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 16

not the waitlist condition, t(12) = -.81, p = .43.

Finally, the CBOSB univariate analyses showed a significant condition X time

interaction, F (1, 25) = 10.28, p = .004, partial η2 = .291. A post-hoc analysis comprised of

PT
paired samples t-tests for each condition showed a significant reduction in the ACT condition,

RI
t(13) = 3.51, p = .004, but not the waitlist condition, t(12) = -.40, p = .7.

Combined Analyses

SC
A 1-way (Time: pretreatment, posttreatment, follow-up) MANOVA on the four measures

NU
showed a significant multivariate main effect for time F(8, 17) = 8.14, p <.001, partial η2 = .97.

Follow-up univariate analyses showed that there were significant effects for time on each
MA
measure. Table 3 shows means and standard deviations at the three time points, as well as

pretreatment to posttreatment and pretreatment to follow-up effect sizes.

D

For the DPVQ, Mauchly’s test of sphericity was violated, χ2(2) = .76, p < .001; therefore,
TE

the Greenhouse-Geisser test is reported. Results showed a univariate significant main effect for
P

time, F(1.37, 24.89) = 28.38, p = .001, partial η2 = .55. Post-hoc analyses using a Bonferroni
CE

correction showed a significant reduction from pretreatment to posttreatment (p = .001), and

AC

pretreatment to follow-up (p = .001), but no significant change from posttreatment to follow-up

(p = .36).

For the QOLS, univariate analyses showed a significant main effect for time, F(2, 48) =

5.1, p = .01, partial η2 = .18. Posthoc analyses using a Bonferroni correction showed a significant

reduction from pretreatment to posttreatment (p = .05), no significant change from pretreatment

to follow-up (p = .24), and no significant change from posttreatment to follow-up (p = .74).

For the SCS, univariate analyses showed a significant main effect for time, F(2, 48) =

35.66, p < .001, partial η2 = .6. Post-hoc analyses using a Bonferroni correction showed a
 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 17

significant reduction from pretreatment to posttreatment (p = .001), and pretreatment to follow-

up (p = .001), but no significant change from posttreatment to follow-up (p = .99).

For the CBOSB, univariate analyses showed a significant main effect for time, F(2, 48) =

PT
36.56, p = .001, partial η2 = .60. Post-hoc analyses using a Bonferroni correction showed a

RI
significant reduction from pretreatment to posttreatment (p = .001), and pretreatment to follow-

up (p = .001), but no significant change from posttreatment to follow-up (p = .99).

SC
Clinically Significant Change

NU
Because the present study is the first to examine a treatment for this problem, there are no

established clinical cutoff scores to evaluate clinical change. To present an indication of clinical
MA
significance from this investigation, the percentage of participants who obtained benchmark

levels of behavioral reduction was calculated. From pretreatment to posttreatment, 14 of 26

D
TE

participants (54%) had a 100% reduction in hours viewing, 17 (66%) had at least a 90%

reduction, 20 (78%) had at least an 80% reduction, and 24 (93%) had at least a 70% reduction. A
P

slight decline in response rates was seen from pretreatment to three month follow-up, where 9 of
CE

25 participants (36%) had a 100% reduction, 14 (56%) had at least a 90% reduction, 17 (68%)
AC

had at least an 80% reduction, and 19 (76%) had at least a 70% reduction.

Discussion

In this study, ACT for problematic pornography use was compared to a waitlist control

condition. The ACT condition showed a significant 93% decrease in hours viewed from

pretreatment to posttreatment compared to a 21% decrease in the control condition. After the

waitlist period, the control condition also received treatment, and results combined with the

original treatment condition showed a 92% reduction from pretreatment to posttreatment, and an

86% reduction from posttreatment to three-month follow-up. This is supported by analyses

 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 18

examining clinically significant change that showed that 54% of participants completely stopped

viewing at posttreatment, and that 93% of participants reduced viewing by at least 70% of

pretreatment levels by posttreatment. Clinical significance at follow-up showed that 35% of

PT
participants had completely stopped viewing and 74% had reduced viewing by at least 70%.

RI
Additional analyses also showed that there was a 33% decrease on measures of sexual

behavior and cognitions. However, there was no evidence that ACT led to increased quality of

SC
life, calling into question its impact on broader functioning. It is possible that improvements in

NU
quality of life do not take place until reductions in pornography viewing have been present for

some time. Finally, independent evaluations showed that the treatment was implemented with
MA
integrity, and low treatment drop-out rates suggest that ACT for pornography viewing is

acceptable to participants.
D
TE

Even though problematic internet pornography use is not a diagnosable disorder, like

many behaviors that can become excessive, it can result in problems with functioning (Coleman
P

et al., 2001; McBride et al., 2008; Reid, 2007). It is also a clinical issue for which clinicians seek
CE

treatment guidance, but for which there are few empirically based suggestions (Del Giudice &
AC

Kutinsky, 2007; Reid & Woolley, 2006; Schneider, 1994; Young, 2007). At a theoretical level,

there are multiple studies showing that psychological inflexibility, the psychological process

addressed in ACT, predicts and mediates the severity of viewing (Levin et al., 2012; Twohig et

al., 2009). However, ours is the only randomized clinical trial addressing this issue. When

coupled with the previous study of ACT for problematic pornography use (Twohig & Crosby,

2010), the emerging picture is that this approach holds promise for helping individuals reduce

levels of this problematic behavior.

 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 19

This research provides some preliminary ideas to support a theoretical understanding of

the nature of problematic viewing of pornography and the theory behind the treatment approach.

Most important is the role of experiential avoidance. As noted in the introduction, there is

PT
evidence to suggest that the way individuals interact with urges (i.e., thoughts, feelings, physical

RI
sensations) to view can result in increased distress and an increased rate of the behavior. In other

words, problematic behaviors are often worsened by a rigid and controlling reaction to the urges

SC
to act on the behavior. The core components of the ACT treatment approach were focused on

NU
changing the way that individuals react to the urges to view so that energy is directed at

managing the behavior, as opposed to managing the urges. The effectiveness of this approach
MA
provides some support that this theoretical approach to the problem is worth further

investigation.
D
TE

Future research should focus on ways to enhance the efficacy of this treatment. Given

that many of our participants were married or had significant others, it might be prudent to
P

involve those individuals in the treatment process. Treatment might also be enhanced by
CE

incorporating additional behavior therapy techniques that have proven to be effective with
AC

impulse control issues such as stimulus management (e.g., limiting physical computer access,

software controls that make viewing more difficult), habit reversal awareness and competing

response training, and more intensive self monitoring (Woods & Twohig, 2008). Maintenance

sessions might also help individuals maintain treatment gains. The ACT treatment protocol used

in this study was not augmented with these additional behavioral strategies to provide a better

experimental test of the core ACT treatment components.

There were several limitations to our study. First, as described in the participant

characteristics section, although our sample was heterogeneous with respect to age and marital
 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 20

status, it was quite homogeneous with respect to sex, race, and geographical region. Religious

affiliation likely played an important role in participant motivation to seek and adhere to

treatment. Although not all individuals will be highly motivated to control their pornography

PT
viewing, there are many conservative religions that prohibit this behavior and many individuals

RI
have a moral stance against it. Second, all of our participants were male, thereby calling into

question the applicability of our findings to women. It is important to note, however, that

SC
pornography viewing tends to be more common among men (e.g., Twohig et al., 2009). Third,

NU
all outcomes were measured via self-report, which is subject to the effects of demand

characteristics, mood-memory effects, and other sources of inaccuracy. Future research should
MA
use objective measures of pornography viewing, such as computer monitoring programs, to

assess outcome. Fourth, our primary outcome variable was a self-report measure of hours spent
D
TE

viewing pornography, and this was not a formally validated measure with known psychometric

properties. Fifth, although this study attempted to experimentally control for threats to internal
P

validity, the waitlist design only controls for the passage of time. Thus, the superiority of the
CE

ACT condition could have been due to common factors of treatment, such as credibility and
AC

expectancy, increased attention to pornography viewing behavior, contact with a therapist, and

other nonspecific variables. There were also several methodological considerations that were not

included in this study, such as the use of an assessor who was unaware of treatment condition.

Finally, although an attempt was made to use multiple therapists, most of the treatment was

provided by a single therapist, which limits the generalizability of findings.

Overall, this study provides empirical evidence for an effective intervention for

problematic pornography use and highlights the need for continued work with this specific

problem, as well as other behavioral addictions. There is a clear need for more accurate
 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 21

prevalence data, continued efforts to clarify the conceptualization of the problem, and further

treatment outcome work.

References

PT
Baer, J. S., Stacy, A., & Larimer, M. (1991). Biases in the perception of drinking norms among

RI
college students. Journal of Studies on Alcohol, 52(6), 580-586.

SC
Black, D. W. (1998). Recognition and treatment of obsessive–compulsive spectrum disorders. In

R. P. Swinson, M. M. Antony, S. Rachman & M. A. Richter (Eds.), Obsessive-

NU
compulsive disorder: Theory, research, and treatment. (pp. 426-457). New York, NY
MA
US: Guilford Press.

Black, D. W., Kehrberg, L. L. D., Flumerfelt, D. L., & Schlosser, S. S. (1997). Characteristics of
D

36 subjects reporting compulsive sexual behavior. The American Journal of Psychiatry,

TE

154(2), 243-249.
P

Burckhardt, C. S., & Anderson, K. L. (2003). The Quality of Life Scale (QOLS): reliability,
CE

validity, and utilization. Health and quality of life outcomes, 1, 60.

Coleman, E. (1991). Compulsive sexual behavior: New concepts and treatments. Journal of
AC

Psychology & Human Sexuality, 4(2), 37-52. doi: 10.1300/J056v04n02_04

Coleman, E., Miner, M., Ohlerking, F., & Raymond, N. (2001). Compulsive Sexual Behavior

Inventory: A preliminary study of reliability and validity. Journal of Sex & Marital

Therapy, 27(4), 325-332. doi: 10.1080/009262301317081070

Collins, R. L., Parks, G. A., & Marlatt, G. A. (1985). Social determinants of alcohol

consumption: The effects of social interaction and model status on the self-administration

of alcohol. Journal of Consulting and Clinical Psychology, 53(2), 189-200. doi:

10.1037/0022-006x.53.2.189
 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 22

Cooper, A., Delmonico, D. L., & Burg, R. (2000). Cybersex users, abusers, and compulsives:

New findings and implications. Sexual Addiction & Compulsivity, 7(1-2), 5-29. doi:

10.1080/10720160008400205

PT
Cooper, A., Delmonico, D. L., Griffin-Shelley, E., & Mathy, R. M. (2004). Online sexual

RI
activity: An examination of potentially problematic behaviors. Sexual Addiction &

Compulsivity, 11(3), 129-143. doi: 10.1080/10720160490882642

SC
Cooper, A., Griffin-Shelley, E., Delmonico, D. L., & Mathy, R. M. (2001). Online sexual

NU
problems: Assessment and predictive variables. Sexual Addiction & Compulsivity, 8(3-4),

267-285. doi: 10.1080/107201601753459964

MA
Cooper, A., Putnam, D. E., Planchon, L. A., & Boies, S. C. (1999). Online sexual compulsivity:

Getting tangled in the net. Sexual Addiction & Compulsivity, 6(2), 79-104. doi:
D
TE

10.1080/10720169908400182

Dedmon, J. (2002). Is the Internet bad for your marriage? Online affairs, pornographic sites
P

playing greater role in divorces. PR Newswire Association LLC.

CE

Del Giudice, M. J., & Kutinsky, J. (2007). Applying motivational interviewing to the treatment
AC

of sexual compulsivity and addiction. Sexual Addiction & Compulsivity, 14(4), 303-319.

doi: 10.1080/10720160701710634

Dodge, B., Reece, M., Cole, S. L., & Sandfort, T. G. M. (2004). Sexual Compulsivity Among

Heterosexual College Students. Journal of Sex Research, 41(4), 343-350. doi:

10.1080/00224490409552241

First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. (2012). Structured Clinical Interview

for DSM-IV® Axis I Disorders (SCID-I), Clinician Version, Administration Booklet:

American Psychiatric Pub.

 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 23

Grant, J. E., & Potenza, M. N. (2010). Impulse control disorders. In J. E. Grant & M. N. Potenza

(Eds.), Young adult mental health. (pp. 335-351). New York, NY US: Oxford University

Press.

PT
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and

RI
commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy,

44(1), 1-25. doi: 10.1016/j.brat.2005.06.006

SC
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An

NU
experiential approach to behavior change. New York, NY US: Guilford Press.

Hilton Jr, D. L., & Watts, C. (2011). Pornography addiction: A neuroscience perspective.
MA
Surgical neurology international, 2, 19.

Kalichman, S. C., Johnson, J. R., Adair, V., Rompa, D., Multhauf, K., & Kelly, J. A. (1994).
D
TE

Sexual sensation seeking: Scale development and predicting AIDS-risk behavior among

homosexually active men. Journal of Personality Assessment, 62(3), 385-397. doi:

P

10.1207/s15327752jpa6203_1
CE

Kalichman, S. C., & Rompa, D. (1995). Sexual sensation seeking and sexual compulsivity
AC

scales: Reliability, validity, and predicting HIV risk behavior. Journal of Personality

Assessment, 65(3), 586-601. doi: 10.1207/s15327752jpa6503_16

Kuzma, J. M., & Black, D. W. (2008). Epidemiology, prevalence, and natural history of

compulsive sexual behavior. Psychiatric Clinics of North America, 31(4), 603-611. doi:

10.1016/j.psc.2008.06.005

Levin, M. E., Hildebrandt, M. J., Lillis, J., & Hayes, S. C. (2012). The impact of treatment

components suggested by the psychological flexibility model: A meta-analysis of

 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 24

laboratory-based component studies. Behavior Therapy, 43(4), 741-756. doi:

10.1016/j.beth.2012.05.003

Levin, M. E., Lillis, J., & Hayes, S. C. (2012). When is online pornography viewing problematic

PT
among college males? Examining the moderating role of experiential avoidance. Sexual

RI
Addiction & Compulsivity, 19(3), 168-180.

Manning, J. C. (2006). The Impact of Internet Pornography on Marriage and the Family: A

SC
Review of the Research. Sexual Addiction & Compulsivity, 13(2-3), 131-165. doi:

NU
10.1080/10720160600870711

Marcks, B. A., & Woods, D. W. (2007). Role of thought-related beliefs and coping strategies in
MA
the escalation of intrusive thoughts: An analog to obsessive-compulsive disorder.

Behaviour Research and Therapy, 45(11), 2640-2651. doi: 10.1016/j.brat.2007.06.012

D
TE

McBride, K. R., Reece, M., & Sanders, S. A. (2008). Predicting negative outcomes of sexuality

using the Compulsive Sexual Behavior Inventory. International Journal of Sexual

P

Health, 19(4), 51-62. doi: 10.1300/J514v19n04_06

CE

Mick, T. M., & Hollander, E. (2006). Impulsive-Compulsive Sexual Behavior. CNS Spectrums,
AC

11(12), 944-955.

Neighbors, C., Lee, C. M., Lewis, M. A., Fossos, N., & Larimer, M. E. (2007). Are social norms

the best predictor of outcomes among heavy-drinking college students? Journal of

Studies on Alcohol and Drugs, 68(4), 556-565.

Orzack, M. H., & Ross, C. J. (2000). Should virtual sex be treated like other sex addictions?

Sexual Addiction & Compulsivity, 7(1-2), 113-125. doi: 10.1080/10720160008400210

 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 25

Owens, E. W., Behun, R. J., Manning, J. C., & Reid, R. C. (2012). The impact of internet

pornography on adolescents: A review of the research. Sexual Addiction & Compulsivity,

19(1-2), 99-122. doi: 10.1080/10720162.2012.660431

PT
Perry, M., Accordino, M. P., & Hewes, R. L. (2007). An investigation of Internet use, sexual and

RI
nonsexual sensation seeking, and sexual compulsivity among college students. Sexual

Addiction & Compulsivity, 14(4), 321-335. doi: 10.1080/10720160701719304

SC
Plumb, J. C., & Vilardaga, R. (2010). Assessing treatment integrity in acceptance and

NU
commitment therapy: Strategies and suggestions. International Journal of Behavioral

Consultation and Therapy, 6(3), 263-295.

MA
Reid, R. C. (2007). Assessing readiness to change among clients seeking help for hypersexual

behavior. Sexual Addiction & Compulsivity, 14(3), 167-186. doi:

D
TE

10.1080/10720160701480204

Reid, R. C., Bramen, J. E., Anderson, A., & Cohen, M. S. (2013). Mindfulness, Emotional
P

Dysregulation, Impulsivity, and Stress Proneness Among Hypersexual Patients. Journal

CE

of clinical psychology.
AC

Reid, R. C., Carpenter, B. N., Hook, J. N., Garos, S., Manning, J. C., Gilliland, R., . . . Fong, T.

(2012). Report of findings in a DSM‐5 field trial for hypersexual disorder. Journal of

Sexual Medicine, 9(11), 2868-2877. doi: 10.1111/j.1743-6109.2012.02936.x

Reid, R. C., & Woolley, S. R. (2006). Using Emotionally Focused Therapy for Couples to

Resolve Attachment Ruptures Created by Hypersexual Behavior. Sexual Addiction &

Compulsivity, 13(2-3), 219-239. doi: 10.1080/10720160600870786

Rinehart, N. J., & McCabe, M. P. (1998). An empirical investigation of hypersexuality. Sexual &

Marital Therapy, 13(4), 369-384. doi: 10.1080/02674659808404255

 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 26

Ross, M. W., Månsson, S.-A., & Daneback, K. (2012). Prevalence, severity, and correlates of

problematic sexual Internet use in Swedish men and women. Archives of Sexual

Behavior, 41(2), 459-466. doi: 10.1007/s10508-011-9762-0

PT
Salisbury, R. M. (2008). Out of control sexual behaviours: A developing practice model. Sexual

RI
and Relationship Therapy, 23(2), 131-139. doi: 10.1080/14681990801910851

Schneider, J. P. (1994). Sex addiction: Controversy within mainstream addiction medicine,

SC
diagnosis based on the DSM-III-R, and physician case histories. Sexual Addiction &

NU
Compulsivity, 1(1), 19-44. doi: 10.1080/10720169408400025

Schneider, J. P. (2000). Effects of cybersex addiction on the family: Results of a survey. Sexual
MA
Addiction & Compulsivity, 7(1-2), 31-58. doi: 10.1080/10720160008400206

Twohig, M. P., & Crosby, J. M. (2010). Acceptance and commitment therapy as a treatment for
D
TE

problematic Internet pornography viewing. Behavior Therapy, 41(3), 285-295. doi:

10.1016/j.beth.2009.06.002
P

Twohig, M. P., Crosby, J. M., & Cox, J. M. (2009). Viewing Internet pornography: For whom is
CE

it problematic, how, and why? Sexual Addiction & Compulsivity, 16(4), 253-266. doi:
AC

10.1080/10720160903300788

Winkler, A., Dörsing, B., Rief, W., Shen, Y., & Glombiewski, J. A. (2013). Treatment of internet

addiction: A meta-analysis. Clinical Psychology Review, 33(2), 317-329. doi:

10.1016/j.cpr.2012.12.005

Woods, D. W., & Twohig, M. P. (2008). Trichotillomania: An ACT-enhanced behavior therapy

approach, therapist guide. New York: Oxford.

Young, K. S. (2007). Cognitive behavior therapy with Internet addicts: Treatment outcomes and

implications. CyberPsychology & Behavior, 10(5), 671-679. doi: 10.1089/cpb.2007.9971

 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 27

Author note:

This paper is based on Jesse Crosby’s dissertation at Utah State University. Dr. Crosby is now at

McLean Hospital / Harvard Medical School, jcrosby@mclean.harvard.edu. Michael Twohig is at

PT
Utah State University, michael.twohig@usu.edu.

RI
Table 1. ACT for Problematic Internet Pornography Use Treatment Components

SC
Session Treatment components Exercises and content
1 Informed consent Warning that therapy may result in emotional discomfort

NU
Commitment to complete all eight sessions
Limits to confidentiality Suicide, homicide, and abuse of children or disabled adults
The viewing of child pornography will be reported
MA
Values Increasing quality of life
Support client goals of either no viewing or reduced and controlled amounts of viewing
Acceptance Identify the distinction between viewing and urges to view
2 Acceptance Short-term vs. long-term effectiveness of attempts to control urges
D

Identify the negative impact of attempts to control urges

Highlight paradoxical nature of attempts to control urges using the Man in the Hole
TE

metaphor
3 Acceptance Reinforce the futility of attempts to control urges
Identify attempts to control urges as part of the problem using the Polygraph, Chocolate
Cake, and What are the Numbers? exercises
P

Discussion of the social contexts that support regulation of private events using the Rule of
Private Events exercise
CE

Introduce acceptance as an alternative to control using the Two Scales metaphor

4 Acceptance Review acceptance by demonstrating that the willingness to experience urges is a chosen
behavior and alternative to control using the Two Scales metaphor
AC

Identify the decrease in effort required to willingly experience urges

Values Brief discussion of client values to give purpose and meaning to acceptance
Discuss what could be gained by letting go of the control agenda
Committed action Behavioral commitments to gradually reduce viewing
Behavioral commitments to engage in value-based activities instead of attempting to control
urges
5-8 Defusion Teach the limits of language and its role in suffering using the Your Mind is Not Your
Friend Intervention
Undermine cognitive fusion using the Passengers on the Bus metaphor
Self as context Identify the self as the context where inner experiences occur using the Chessboard
metaphor
Explain that the client does not choose what inner experiences occur, but that they can
choose what to do with them
Contact with present Help the client be present with their inner experiences using the Awareness of Inner
moment Experiences exercise
Identify the importance of being present while not being heavily attached to inner
experiences
Acceptance Identifying opportunities for acceptance from out of session practice
Encourage acceptance of any problematic inner experiences
 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 28

Session Treatment components Exercises and content

Committed action Behavioral commitments to continue to reduce viewing
Behavioral commitments to engage in value-based activities instead of attempting to control
urges
9-10 Values Define the concept of values
Clarify the client’s values and assess the consistency of the his/her behavior with those

PT
values using the Values Assessment Homework
Committed action Behavioral commitments to continue reduced viewing
Increased behavioral commitments to engage in valued living based on recent values work

RI
Discussion of relapse management using the ACT skills
11 Review Review any processes that still need attention

SC
12 Termination Summarize the treatment using the Joe the Bum metaphor
Apply ACT processes to relapse management
Apply ACT processes to termination
Suggest Get Out of Your Mind and Into Your Life workbook for continued progress

NU
Note. Italicized exercises are from Hayes and colleagues (1999).
MA
D
P TE
CE
AC
 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 29

Table 2. Means, Standard Deviations, and Effect Sizes for Between Condition Analyses

ACT Condition Waitlist

(n = 14) (n = 13)
──────────────────── ────────────────────

PT
Pretreatment Posttreatment Pretreatment Posttreatment
───────── ──────── ───────── ─────────
Variable M SD M SD d M SD M SD d

RI
Self-report hours viewing 6.13 4.51 0.43 0.64 1.8 6.85 5.99 5.40 3.49 0.29
(per week)

SC
Quality of life (QOLS) 82.79 11.58 85.36 11.17 0.22 77.23 12.42 73.62 11.89 0.29
Sexual compulsivity (SCS) 30.43 8.36 20.36 7.27 1.28 31.15 7.36 30.08 6.87 0.07
Cognitive outcomes 38.14 5.19 30.64 5.30 1.43 39.77 5.42 40.23 5.66 -0.08

NU
(CBOSB)

Note: Cohen’s d was calculated using pooled standard deviation. All effect sizes are based on
MA
change scores from pretreatment.
D
P TE
CE
AC
 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 30

Table 3. Means, Standard Deviations, and Effect Sizes for Combined Analyses

Pretreatment Posttreatment Follow Up

(n = 27) (n = 26) (n = 25)
───────── ────────────── ───────────────
Variable M SD M SD d M SD d

PT
Self-report hours viewing (per week) 5.65 4.01 0.47 0.80 1.79 0.77 1.10 1.66
Quality of life (QOLS) 78.37 12.42 85.77 9.98 0.65 84.32 12.06 0.48

RI
Sexual compulsivity (SCS) 30.26 7.54 19.15 6.44 1.58 19.72 7.65 1.38
Cognitive outcomes (CBOSB) 38.79 5.22 29.65 5.76 1.65 28.8 5.7 1.83
Note: Cohen’s d was calculated using pooled standard deviation. All effect sizes are based on

SC
change scores from pretreatment.

NU
MA
D
P TE
CE
AC
 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 31

Figure 1. Participant flow throughout the study

Did Not Respond After Response to Recruitment (n=66)

Initial Contact (n=23)
Unable to Make Time

PT
Commitment (n= 4) Assessed for Eligibility (n=39)
Excluded Total (n=11)
Did Not Meet Criteria (n=11)
Refusal to Participate (n=0)
Enrolled (n=28)

RI
SC
Pretreatment Assessment (n=28)

Random Assignment (n=28)

NU
ACT Condition (n=14)
MA Control (Waitlist) Condition (n=14)

Received Intervention (n=14) Completed Waiting Period (n=13)

D

Post Treatment Assessment (n=14) Post Waiting Period Assessment (n=13)

TE

Pre to Post Analysis (n=14) Pre to Post Analysis (n=13)

P
CE

Follow Up Assessment (n=13) Received Intervention (n=13)

Follow Up Analysis (n=13) Post Treatment Assessment (n=12)

AC

Combined Pre to Post Analysis (n=12)

Follow Up Assessment (n=12)

Combined FollowUp Analysis (n=12)

 ACCEPTED MANUSCRIPT
ACT for Internet Pornography 32

HIGHLIGHTS

 Acceptance and commitment therapy is more effective than waitlist in reducing viewing
 Acceptance and commitment therapy had positive effects on related sexual behaviors
 Results were maintained at three month follow-up

PT
RI
SC
NU
MA
D
P TE
CE
AC